Basic Information
| Provider Information | |||||||||
| NPI: | 1528053857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANFORD | ||||||||
| FirstName: | CLYDE | ||||||||
| MiddleName: | FAGG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 703 S FLEISHEL AVE | ||||||||
| Address2: | STE 4000 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036067000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | E9970 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | E9970 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 089421J | 01 | TX | BCBS | OTHER | 038665009 | 01 | TX | UNITED HEALTHCARE | OTHER | 128834202 | 05 | TX | MEDICAID | 4538099 | 01 | TX | AETNA | OTHER | 128834206 | 05 | TX | MEDICAID | 752616977007 | 01 | TX | TRICARE | OTHER |